HAJ COMMITTEE OF INDIA

ONLINE HAJ APPLICATION FORM FOR HAJ – 2024 (C.E.) 1445 (Hijri)

231230202079544
1 .Category General Cover No.
2. No. of Persons 2 No. of Infant 0
3. Name of Cover Head MOHAMMAD SAMUN Embarkation Preference 1 /
AKBAR HUSAIN KHAN 2 : MUMBAI / MUMBAI

4. Applicant’s Details (As per International Passport)

Passport Number T6253603 Place of Issue PUNE Date of Issue 19-06-2019

Date of Expiry 18-06-2029 Date of Birth 25-12-1962 Place of Birth AHMEDNAGAR
Surname KHAN First Name MOHAMMAD SAMUN Father’s Name AKBAR HUSAIN
Gender Male Mother’s Name TARABUNISSA Spouse’s Name NOORJAHAN
Marital Status MARRIED Blood Group AB+ Qualification PRIMARY
Occupation BUSINESS Aadhaar No. 7285-9703-6787 PAN No. ALMPK8048D
Companion Name Companion Relation NA

5. Health Details

Detail of Co-Morbidity Diabetes Pregnancy Status NA

Vaccine Name Covaxin

Dose 1 Date 14-09-2022 Dose 2 Date 13-10-2022 Precaution Dose Date

6. Present Residential Address

PLOT NO 37 SAINAGAR
Address NAVNAGAPUR Pincode 400099
AHMEDNAGAR
State Maharashtra District Ahmednagar
Mobile Number 9673963636 Mobile Number 2 8504043636 Email Id rustamkh555@gmail.com

7. Details of Nominee of Applicant

RUSTAM MOHAMMAD
Name Mobile Number : 9673963636
SAMUN KHAN

Father’s /Husband’s Name MOHAMMAD SAMUN

KHAN
Relationship SON
PLOT NO 37 SAINAGAR
Address NAVNAGAPUR Pincode 414111
AHMEDNAGAR
Signature / Thumb impression
State Maharashtra District Ahmednagar
of Nominee

8. Name of Mehram with Relation (applicable for female pilgrims only)

Name NA Relationship: NA
Signature / Thumb impression
Passport No. NA
of Mehram

9. Bank Account Details

MOHAMMED SAMUN
Name of Account Holder Bank Name AXIS BANK
KHAN
Account No. 215010100012856 IFSC Code UTIB0000215

10. Are you (a) permissible Repeater Mehram / Campanion of age 70+ pilgrim? NO
11. Do you want to perform ADAHI (Qurbani) through IDB ? YES
12. Opting JOHFA Meeqat (only for Shia pilgrims) NO
13. Whether willing to avail facility of Rubat? NO
14. Are you NRI? NO
15. Status of disabilities and type of assistance needed? NA
16. Whether willing to avail Metro facilities in KSA for local travel? NO

• I hereby undertake to abide by all the guidelines, including health protocol, age and travel restrictions, etc. issued by the Kingdom of Saudi Arabia and the Government of India/Haj
Committee of India in view of CoVID-19 pandemic. I agree to travel to the Embarkation Point allotted to me and am ready to pay all the charges on all accounts. I am also willing to go
through the RT-PCR test and quarantine period as specified in the protocol and guidelines
• I am aware of the tentative cost of Haj 2024, which may vary due to operational or functional reasons.
• I certify that the information furnished above is true and correct.

Signature / Thumb impression of the Applicant

FOR OFFICE USE ONLY

Online HAF Checked by Verified by Executive Officer, State / UT Haj Committee
All entries in the above HAF have been checked and found to be in order. Certified that the applicant is eligible to register for Haj-2024 (CE). 1445 (Hijri)
 SOLEMN DECLARATION AND UNDERTAKING

For General Category

I, Mr./Mrs./Miss MOHAMMAD SAMUN AKBAR HUSAIN KHAN S/o./W/o./D/o. AKBAR HUSAIN, an Indian citizen, do hereby solemnly affirm and
declare as under:
1. I am aware that, as per Government of India policy, a person can perform Haj only "Once in a Lifetime" through the Haj Committee of India (HCol).
2. I have never performed Haj through the HCol in the past, and hence I am eligible to apply for Haj - 2024 (Hijri - 1445). I am aware that repeaters are
not eligible for Haj - 2024 (Hijri- 1445) and if it is detected at any stage that I have already performed Haj through HCoI, my seat shall be cancelled and
the entire amount deposited shall be forfeited.
3. I have read / understood thoroughly the Guidelines for Haj - 2024 (Hijri - 1445), particularly with reference to eligibility, cost, payments and
confirmation, cancellation, refunds, embarkation points, vaccination and health requirements before flight, baggage, flight, and accommodation in
Kingdom of Saudi Arabia, and I undertake to abide by the same.
4. I hereby authorize HCol to send SMS to my mobile phone number, even if I am on the DND registry.
5. The particulars given by me in HAF, the solemn declaration, and the undertaking are true and correct to the best of my knowledge. I do hereby affirm
and declare that in the event I have suppressed material information or given a false / incorrect declaration / undertaking, HCoI shall forfeit the amount
deposited by me and I shall be liable for prosecution.
6. I am aware that HCol reserves the right to change the Embarkation point opted by me. In such a case, I shall abide by the decision of HCol and shall
not show any resentment, whatsoever, against the decision of HCoI. I hereby agree to pay the Airfare finalized through the bids for each Embarkation
Point and shall not represent against that.
7. I am ready to pay extra charges, as levied by the KSA Haj authorities, for the endorsement of my Haj visa.
8. I/We understand that the HCoI works without profit motive and does not attract the provisions of the Consumer Protection Act, 2019.
9. Further, we understand that the Courts of Greater Mumbai alone shall have jurisdiction in all matters of dispute.
10. I understand that if I am found carrying khas-khas, viagra-tablets, sexual oil and creams, synthetic capore, cystone, khammera, gutkha, khaini, gul,
peppermint, or narcotics in any form, my candidature shall be cancelled. Besides, I will be penalized for carrying banned items as per the prevailing
regulations of Saudi Arabia, and I will be liable for deportation to India from KSA at any stage of Haj.
11. I hereby agree that the Rubat and metro transport facilities will be subject to the terms and conditions of KSA, and that if this is not possible, I will be
obligated to pay charges for the services provided to me.
12. I do not have any criminal prosecutions pending against me.
13. I am medically fit to perform the Haj pilgrimage and do not have any contagious diseases.
14. I understand that accommodation in Madinah is subject to availability, I may be allotted accommodation in Markazia or Non Markazia as per the
availability. I will accept the accommodation provided to me, which is approved by the authorities in KSA.

Date:___________________________

Place:___________________________

Signature / Thumb impression of the applicant.

 HAJ COMMITTEE OF INDIA
ONLINE HAJ APPLICATION FORM FOR HAJ – 2024 (C.E.) 1445 (Hijri)
Adult Pilgrim Detail : 2

231230202079544
1 .Category General Cover No.
2. No. of Persons 2 No. of Infant 0
3. Name of Cover Head MOHAMMAD SAMUN Embarkation Preference 1 /
AKBAR HUSAIN KHAN 2 : MUMBAI / MUMBAI

4. Applicant’s Details (As per International Passport)

Passport Number T6255563 Place of Issue PUNE Date of Issue 20-06-2019

Date of Expiry 19-06-2029 Date of Birth 03-04-1965 Place of Birth AHMEDNAGAR
Surname KHAN First Name NOORJAHAN Father’s Name MANULLA NABIJAN KHAN

Gender Female Mother’s Name JAUDANI Spouse’s Name MOHAMMAD SAMUN

KHAN
Marital Status MARRIED Blood Group A+ Qualification PRIMARY
Occupation HOUSE WIFE Aadhaar No. 9097-9889-8469 PAN No. ALMPK8049C
Companion Name Companion Relation NA

5. Health Details

Detail of Co-Morbidity Not Applicable Pregnancy Status No

Vaccine Name Covaxin

Dose 1 Date 14-09-2022 Dose 2 Date 13-10-2022 Precaution Dose Date

6. Present Residential Address

PLOT NO 37 SAINAGAR
Address NAVNAGAPUR Pincode 400099
AHMEDNAGAR
State Maharashtra District Ahmednagar
Mobile Number 9673963636 Mobile Number 2 8504043636 Email Id rustamkh555@gmail.com

7. Details of Nominee of Applicant

Name MOHAMMAD SAMUN Mobile Number : 9673963636

Father’s /Husband’s Name AKBAR HUSAIN
Relationship HUSBAND
PLOT NO 37 SAINAGAR
Address NAVNAGAPUR Pincode 414111
AHMEDNAGAR
Signature / Thumb impression
State Maharashtra District Ahmednagar
of Nominee

8. Name of Mehram with Relation (applicable for female pilgrims only)

MOHAMMAD SAMUN
Name Relationship: HUSBAND
KHAN
Signature / Thumb impression
Passport No. T6253603
of Mehram

9. Bank Account Details

MOHAMMED SAMUN
Name of Account Holder Bank Name AXIS BANK
KHAN
Account No. 215010100012856 IFSC Code UTIB0000215

10. Are you (a) permissible Repeater Mehram / Campanion of age 70+ pilgrim? NO
11. Do you want to perform ADAHI (Qurbani) through IDB ? YES
12. Opting JOHFA Meeqat (only for Shia pilgrims) NO
13. Whether willing to avail facility of Rubat? NO
14. Are you NRI? NO
15. Status of disabilities and type of assistance needed? NA
16. Whether willing to avail Metro facilities in KSA for local travel? NO

• I hereby undertake to abide by all the guidelines, including health protocol, age and travel restrictions, etc. issued by the Kingdom of Saudi Arabia and the Government of India/Haj
Committee of India in view of CoVID-19 pandemic. I agree to travel to the Embarkation Point allotted to me and am ready to pay all the charges on all accounts. I am also willing to go
through the RT-PCR test and quarantine period as specified in the protocol and guidelines
• I am aware of the tentative cost of Haj 2024, which may vary due to operational or functional reasons.
• I certify that the information furnished above is true and correct.

Signature / Thumb impression of the Applicant

FOR OFFICE USE ONLY

Online HAF Checked by Verified by Executive Officer, State / UT Haj Committee
All entries in the above HAF have been checked and found to be in order. Certified that the applicant is eligible to register for Haj-2024 (CE). 1445 (Hijri)
 SOLEMN DECLARATION AND UNDERTAKING

For General Category

I, Mr./Mrs./Miss NOORJAHAN MOHAMMAD SAMUN KHAN S/o./W/o./D/o. MANULLA NABIJAN KHAN, an Indian citizen, do hereby solemnly affirm
and declare as under:
1. I am aware that, as per Government of India policy, a person can perform Haj only "Once in a Lifetime" through the Haj Committee of India (HCol).
2. I have never performed Haj through the HCol in the past, and hence I am eligible to apply for Haj - 2024 (Hijri - 1445). I am aware that repeaters are
not eligible for Haj - 2024 (Hijri- 1445) and if it is detected at any stage that I have already performed Haj through HCoI, my seat shall be cancelled and
the entire amount deposited shall be forfeited.
3. I have read / understood thoroughly the Guidelines for Haj - 2024 (Hijri - 1445), particularly with reference to eligibility, cost, payments and
confirmation, cancellation, refunds, embarkation points, vaccination and health requirements before flight, baggage, flight, and accommodation in
Kingdom of Saudi Arabia, and I undertake to abide by the same.
4. I hereby authorize HCol to send SMS to my mobile phone number, even if I am on the DND registry.
5. The particulars given by me in HAF, the solemn declaration, and the undertaking are true and correct to the best of my knowledge. I do hereby affirm
and declare that in the event I have suppressed material information or given a false / incorrect declaration / undertaking, HCoI shall forfeit the amount
deposited by me and I shall be liable for prosecution.
6. I am aware that HCol reserves the right to change the Embarkation point opted by me. In such a case, I shall abide by the decision of HCol and shall
not show any resentment, whatsoever, against the decision of HCoI. I hereby agree to pay the Airfare finalized through the bids for each Embarkation
Point and shall not represent against that.
7. I am ready to pay extra charges, as levied by the KSA Haj authorities, for the endorsement of my Haj visa.
8. I/We understand that the HCoI works without profit motive and does not attract the provisions of the Consumer Protection Act, 2019.
9. Further, we understand that the Courts of Greater Mumbai alone shall have jurisdiction in all matters of dispute.
10. I understand that if I am found carrying khas-khas, viagra-tablets, sexual oil and creams, synthetic capore, cystone, khammera, gutkha, khaini, gul,
peppermint, or narcotics in any form, my candidature shall be cancelled. Besides, I will be penalized for carrying banned items as per the prevailing
regulations of Saudi Arabia, and I will be liable for deportation to India from KSA at any stage of Haj.
11. I hereby agree that the Rubat and metro transport facilities will be subject to the terms and conditions of KSA, and that if this is not possible, I will be
obligated to pay charges for the services provided to me.
12. I do not have any criminal prosecutions pending against me.
13. I am medically fit to perform the Haj pilgrimage and do not have any contagious diseases.
14. I understand that accommodation in Madinah is subject to availability, I may be allotted accommodation in Markazia or Non Markazia as per the
availability. I will accept the accommodation provided to me, which is approved by the authorities in KSA.

Date:___________________________

Place:___________________________

Signature / Thumb impression of the applicant.